the contents of the cribriform fascia exit the femoral triangle at this
location

superficial/external pudendal a/v

superficial epigastric a/v

superficial circumflex iliac a/v

the great saphenous vein

anterior femoral cutaneous nn pierce fascia lata anterior.

further discussion

The saphenous hiatus

is a specialization of the fascia lata located in the anteromedial thigh
just inferior to the inguinal ligament and superficial to the femoral sheath.
The lateral margin overlies the femoral artery. The medial aspect
overlies the femoral canal. Superiorly is the inguinal ligament.
Approximately 2cm inferior to the inguinal ligament is the inferior cornu
over which the great saphenous vein forms an arch as it leaves superficial
fascia and enters the femoral vein. Notable tributaries of the great
saphenous vein within the saphenous hiatus are the external pudendal vein
coursing medially, the superficial epigastric vein coursing superiorly,
and the superficial circumflex iliac vein coursing laterally and superiorly.
Accompanying these veins are branches of the femoral artery. These
vessels are piercing through the surrounding cribriform fascia. The
distinct lateral margin of the saphenous hiatus is the falciform edge.
There are superior and inferior borders referred to as the superior and
inferior cornu. Medially, the hiatus is indistinct and blends with
the pectineus fascia. The femoral ring is located immediately deep
to the medial aspect of the saphenous hiatus. A femoral hernia, if
present, can be palpated at this location. Additionally, a femoral
pulse can be located and, thus, easy surgical access to a major artery
or vein is possible.

Femoral canal

Lymph funnel shaped lymph channel located in the most medial compartment
of the femoral sheath.

Femoral ring is at the superior opening of this canal.

Formed by an 1.5cm extension of transversalis fascia from the abdominal
cavity into the thigh.

Exposed to superficial fascia by the saphenous hiatus.

Site of femoral hernia

more common in females because of wider pelvic bones and larger femoral
ring.

2. Review the anatomy of the knee joint and include bones, articulations,
ligaments, cavities and bursa, vasculature, muscles, and fascial specializations
that contribute to the stability of the knee joint. State when and
why the knee joint is maximally stabilized. (15 pts)

Bones and Articulations (x pts)

Synovial hinge joint between the femoral and tibial condyles.

Tibial plateau is cupped by the medial and lateral menisci.

Femoral condyles

Patella articulates anteriorly as a sesamoid bone in the quadriceps tendon.

small branches of the femoral, obturator, and sciatic, and tibial nerves
pierce the joint capsule.

"Screw Home" (x pts)

Consider when the knee is extended with the foot planted on the ground.
In this case, the tibia is fixed by virtue of the planted foot. Thus, rotation
of the knee occurs as movement of the femur. The femur rotates medially
as the knee "locks" in extension. The lateral femoral condyle is smaller
than the medial femoral condyle. As the knee is extended the smaller condyle
moves through its arc before the medial condyle. Thus, movement stops at
the lateral condyle while the femoral medial condyle continues to move
further posteriorly. This movement results in a medial rotation of the
femur.

This medial rotation torques the joint capsule and it's ligamentus specializations
(medial and later collateral ligs). The "twisting" of the capsular
ligaments causes the region to tighten. This firmly approximates the femoral
condyles to the tibial plateau and "locks" the knee. The femur "screws"
medially onto the tibial plateau due to the larger medial condyle and the
twisting of the capsular ligaments. On extension, the knee goes through
a "screw home" rotation that results in "close packing."

The final medial rotation of the femur is driven by the line of gravity
moving anterior to the axis of the knee joint. Thus, locking the
knee is driven by gravity. Unlocking the knee requires muscular involvement.
The popliteus, having lateral superior to medial inferior attachments,
posterior to the axis of the knee, can to lateral rotate the femur
(reverse origin and insertion) and, thus, unlock the knee joint.

3. A 35-yr old male arrives in the clinic with a nail that penetrates
the sole of the foot and pierces the spring ligament. Discuss the
fascia, muscles, tendons, nerves (including cutaneous innervation), bones,
and vasculature involved with such an injury. (10 pts)

Skin and plantar aponeurosis

Medial plantar a. and v.

The lateral plantar a.v. is posterio-lateral to site of penetration and
is spared

The sinoatrial node is a crescent shaped heart region about 8mm long and
located at the superior aspect of the sulcus terminalis within the wall
of the right atrium. It is referred to as the pacemaker of the heart
owing to its electrical characteristics and crucial role in timing of the
cardiac cycle. The SA node connects to the AV node by internodal
tracts.

vascular supply

anterior cardiac vv

small cardiac vv

marginal branch of right coronary

sinuatrial artery - nodal branch to SA node

5. Describe the lymphatic drainage of the breast. (6 pts)

Laterally, lymph drainage from the breast is into groups of axillary nodes.
Most of this drainage is into the pectoral nodes located along pectoral
branches of the thoracoacromial vessels. Pectoral nodes drain into the
apical nodes located near the apex of the axilla. On the left, the
axillary nodes give rise to the subclavian lymphatic trunk. This vessel
commonly drains into the thoracic duct and then the angle of internal jugular.
The right subclavian duct often drains directly into the venous system.
Apical nodes also have drainages into cervical and supraclavicular nodes.
Metastatic disease in these nodes is especially difficult to remove.

The medial aspect of the breast is drained by intercostal vessels into
parasternal nodes. Parasternal and paratrachial drainages combine
to form the bronchomediastinal lymph trunks. Drainage continues into
the right lymphatic duct on the right and the thoracic duct on the left.

The breast is also drained by subcutaneous vessels. These vessels
have a wide distribution ranging from the cervical region to the inguinal
region and crossing the midline. If the deeper lymph channels are
blocked, as may be the case with cancer, subcutaneous drainage may greatly
increase and widely disperse cancerous cells.

axillary notes receive 75% of lymphatic drainage

pectoral nodes - lateral border of pectoralis major
apical nodes - beneath the clavicle
parasternal nodes
along the internal thoracic artery
subcutaneous lymphatics
distribute to wide area if deep lymphatics are blocked (e.g. cancer)
left/right differences
right side into right (subclavian) lymph duct
left side into thoracic duct and left subclavian v.

Summary

Laterally, lymph drainage from the breast is into groups of axillary
nodes. Most of this drainage is into the pectoral nodes located along
pectoral branches of the thoracoacromial vessels. Pectoral nodes drain
into the apical nodes located near the apex of the axilla. On the
left, the axillary nodes give rise to the subclavian lymphatic trunk. This
vessel commonly drains into the thoracic duct and then the angle of internal
jugular. The right subclavian duct often drains directly into the
venous system. Apical nodes also have drainages into cervical and
supraclavicular nodes. Metastatic disease in these nodes is especially
difficult to remove.
The medial aspect of the breast is drained by intercostal vessels into
parasternal nodes. Parasternal and paratrachial drainages combine
to form the bronchomediastinal lymph trunks. Drainage continues into
the right lymphatic duct on the right and the thoracic duct on the left.
The breast is also drained by subcutaneous vessels. These vessels
have a wide distribution ranging from the cervical region to the inguinal
region and crossing the midline. If the deeper lymph channels are
blocked, as may be the case with cancer, subcutaneous drainage may greatly
increase and widely disperse cancerous cells.